a. Observatory of the Amusing Determinants of Health, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.b. Universidade de Brasília, Campus Universitário Darcy Ribeiro, 70910-900, Brasília – DF, Brazil.
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Correspondence to Leonor Maria Pacheco Santos (e-mail: [email protected]).
(Submitted: 28 December 2010 – Revised adaptation received: 25 March 2011 – Accepted: 28 March 2011 – Published online: 29 April 2011.)
Bulletin of the World Bloom Organization 2011;89:496-503. doi: 10.2471/BLT.10.084202
Recently, codicillary banknote alteration programmes accept sparked ample interest. This amusing aegis action has been acclimated both to advance amusing development and on altruistic grounds.1 Within a bulk of 10 years codicillary banknote alteration programmes accept become the amusing action of best in Latin America, which has set examples in this annual for added developing regions.2 From 2001 to 2003 Brazil created four banknote alteration programmes that were alloyed into the Bolsa Familia programme (BFP)3 in backward 2003 and afterwards expanded. The new programme has accumulated administration and accomplishing processes and was devised for the purpose of: (i) promoting admission to the attainable casework network, decidedly in health, apprenticeship and amusing protection; (ii) combating ache and announcement aliment and diet security; (iii) stimulating the abiding empowerment of families active in abjection and acute poverty; (iv) fighting poverty; (v) promoting accessory amusing action amid authoritative and nongovernmental sectors.4 The BFP seeks to advance in animal capital, by advertence banknote transfers with educational goals and uptake of bloom services.
The BFP is the world’s bigger codicillary banknote alteration programme. It alcove all 5564 municipalities in the 27 states of Brazil and about 11 actor families,5 or about 46 actor bodies (25% of the Brazilian population). The programme’s legislation guarantees complete banknote transfers to: (i) families in abjection or acute abjection (household assets per capita beneath 44.00 United States dollars, US$, and beneath US$ 22.00, respectively, in 2005–06); (ii) families composed of accouchement from 0 to 15 years of age; and (iii) families with a abundant or lactating woman. In 2008, the age accumulation for the accouchement was continued to 17 years. In best cases the banknote alteration is paid to the advertence changeable of the ancestors group. The per capita assets cut-offs and the belief of banknote transferred are readjusted every two years or so, by decree. The bulk per ancestors depends on the abjection beginning and ancestors composition. No diet supplement is distributed. Details of how the BFP operates are presented in a World Bank publication.6
Once a ancestors enrols, it charge accede with assertive bloom and apprenticeship altitude to abide in the programme: (i) a minimum academy appearance of 85% of the annual academy hours for accouchement 7 to 17 years old; (ii) a bloom and diet calendar for almsman families with abundant women, nursing mothers or accouchement beneath 7 years of age (pre-natal care, vaccination, bloom and diet surveillance).4
Every two years the advice in the Unified Registry (CadUnico) charge be adapted with anniversary family’s best contempo address, application and socioeconomic status. This action is organized by the bounded amusing services, and ancestors payments can be abeyant or annulled if there is affirmation of adolescent labour, artifice or the advised accouterment of incorrect information, if the family’s socioeconomic altitude advance (resulting in awkwardness for BFP), or if a ancestors fails to accede with accustomed conditions.
Some studies accept advised the furnishings of the BFP on abjection and inequity,7 aliment expenditure,8,9 apprenticeship and bloom annual uptake8 and aliment security.10,11 Best of these publications were afresh reviewed.5 Their after-effects will be presented and discussed abroad in this manuscript.
Since 2005 the Brazilian government has answer alternate surveys accepted as Bloom and Diet Days to appraisal the prevalence of anthropometric deficits in accouchement up to the age of 5 years application the window of befalling offered by Civic Immunization Days.12 This action saves time and money because the immunization activities agreement civic mobilization and the personnel, bloom accessories and accessories all-important to conduct the surveys. Therefore, accumulation these two accumulation activities improves able use of attainable resources. In Brazil anesthetic advantage during Civic Immunization Days is able-bodied aloft 95%, which makes alternative bent during a Bloom and Diet Day awful unlikely.12
The cold of this abstraction is to analyze abeyant associations amid enrolment in the BFP and the anthropometric indicators acme for age, weight for age and weight for acme in accouchement beneath 5 years of age.
We active abstracts sets from four cross-sectional Bloom and Diet Day surveys, which included 22 927 accouchement from 419 municipalities in 23 Brazilian states. Of the sampled children, 30.1% lived in rural areas. During the aboriginal investigations, conducted in 2005–2006, population-based probabilistic samples of accouchement beneath than 5 years of age were selected. Sample sizes were afflicted for statistical adeptness as declared in the aboriginal publications12–16 and they accustomed inferences to be fatigued for added than three actor children.12 The surveys focused on low-income regions and underprivileged populations in Brazil: 277 municipalities in the north-eastern semi-arid region; 75 agrarian ameliorate settlements in 40 north-eastern municipalities; 60 rural quilombola (Maroon) communities broadcast nationwide, and 42 baby municipalities in the Amazon accompaniment (North Region).
Details of abstracts accumulating and affection ascendancy procedures were appear elsewhere.14 In short, bounded teams of bristles bodies were accomplished to aggregate abstracts during Civic Immunization Days. Special absorption was accustomed to demography two anthropometric abstracts for anniversary child, as recommended by the World Bloom Organization (WHO). A two-page check calm advice about both parents’ educational background; admission to domiciliary goods, attainable casework and amusing benefits; bearing weight and advance ecology (from the Adolescent Bloom Card); breastfeeding; accepted adolescence diseases and acquiescence with prenatal care.14 Questionnaires were scanned to body the abstracts set. The believability of the anthropometric abstracts was arrested by artful the complete aberration amid the two anthropometric measurements. If this was greater than 1 cm in acme (172 cases) or 0.2 kg in weight (213 cases), the abstracts were advised imprecise.14 Modelling with polynomial and beeline corruption was acclimated to exclude these estimated abstracts and verify boilerplate acme and weight abstracts adjoin age.14 Anthro 2006 software (WHO, Geneva, Switzerland) was active to appraise comestible cachet in accordance with the WHO Adolescent Advance Standards.17 The anthropometric indices were bidding as Z scores, which represent accepted deviations (SDs) of the advertence population, with the absolute set at beneath than −2.00 SD as recommended by WHO.18
After the four databases were unified and thoroughly verified, the final chip abstracts set included 22 375 accouchement beneath 5 with accurate abstracts (97.6% of total). Missing or abridged abstracts for any of the absolute variables beneath abstraction led to the accident of 2.4% of the children. The frequencies of amusing and demographic characteristics were afflicted with SPSS (SPSS Inc., Chicago, United States of America). The χ2 assay was acclimated back appropriate, with alteration for continuity, and the acceptation akin was set at P
For the statistical assay based on logistic regression, acme for age, weight for age and weight for acme were the abased variables. These were adapted to bifold variables and classified as able if ≥ −2.00 SD, according to WHO recommendations. We again estimated the allowance ratios (ORs) amid the accouchement apparent and not apparent to the afterward variables: (i) BFP banknote alteration (independent variable); and the afterward amid variables: (ii) birth weight > 2.5 kg; (iii) lack of bearing certificate; (iv) family arch ancestry ≥ 5 years; (v) male ancestors head, (vi) household with electrical supply; (vii) household with piped water. Bearing weight was included in the archetypal because it acts as an amid capricious (i.e. accouchement with low bearing weight may crave abounding months, or alike years, to bolt up with able growth). The added amid variables were included in the archetypal as proxies of the families’ socioeconomic cachet and domiciliary ecology conditions. We advised the accord amid these six amid variables and the three abased variables to analyze attainable causal links on which to abject added able-bodied studies. The statistical amalgamation SAS (SAS Institute, Cary, USA) was acclimated to accomplish corruption assay and to appraisal 95% aplomb intervals (CIs).
The Bloom and Diet Day protocols were accustomed by the belief committees of the Civic Academy of Attainable Bloom and the Civic Amazonian Research Institute. Children’s guardians were abreast about the assay and active abreast accord forms. Anthropometric after-effects were appear to them anon and astringent cases of angular were referred to the primary-health-care service.
Table 1 shows the social, demographic and bloom characteristics of the accouchement advised as a action of acknowledgment to the BFP. Bloom and Diet Day activities were advised to adeptness subgroups of underprivileged and bankrupt populations, as apparent by the amusing and bread-and-butter indicators disclosed.
Many of the variables activated did not alter decidedly amid groups. There was ample and cogent asymmetry in adolescent age accumulation and ancestors arch schooling. The afterwards aberration confirms that BFP is able-bodied targeted.
Table 2 shows the after-effects of corruption analyses with adjustments for six health, amusing and bread-and-butter variables. A adolescent age-old beneath than 5 years enrolled in the BFP had a 26% college adventitious of accepting able acme for age and weight for age than a adolescent not enrolled. No affiliation was begin amid enrolment in the BFP and weight for height.
Independent of acknowledgment to the BFP, accustomed bearing weight and abridgement of a bearing affidavit were associated with all the anthropometric indicators examined. Accouchement with accustomed bearing weight were from 2.2 to 4.5 times added acceptable to accept able anthropometric indices. Accouchement with low bearing weight started activity at a disadvantage and would crave months or years to adeptness able weight and acme for age. The abridgement of a bearing affidavit was decidedly associated with deficits in all three anthropometric indicators. Ancestors arch ancestry of at atomic 5 years was associated with bare acme for age and weight for age.
When we stratified by age group, accouchement earlier than 12 months enrolled in the BFP were added acceptable to accept able acme for age than accouchement the aforementioned age who were not enrolled; however, this aftereffect was not apparent in accouchement beneath than 12 months of age (Table 3). Accouchement age-old 12–35 months and 36–59 months enrolled in the BFP had 19% and 41% college affairs of accepting able acme for age, respectively, than accouchement not apparent to the BFP. As expected, bearing weight was associated with acme for age abundant added acerb during the aboriginal year of activity than at earlier ages.
The abridgement of a bearing affidavit during the aboriginal year of activity showed no affiliation with acme for age. However, it was associated with 57% and 59% college affairs of accepting low acme for age in accouchement age-old 12–35 and 36–59 months, respectively. The abridgement of the affidavit afterwards in adolescence is apparently an indicator of acute abjection and of abode in an abandoned area; both of which anticipate families from accepting the certificates and additionally advance to bare growth.
Co-linearity was activated for and is actual unlikely. Cramer´s V coefficients were afflicted pairwise for the advised variables and assorted from 0.0205 to 0.2226. The accomplished bulk was acquired back acknowledgment to the BFP was compared with the ancestry of the arch of household.
Cross-sectional studies present inherent limitations. In this accurate case the breadth of acknowledgment to BFP banknote transfers was not determined, and neither were the attainable biases accompanying to enrolment in banknote alteration programmes added than the BFP, about unlikely. In addition, some variables that could not be measured, such as ancestors income, aliment burning and comestible cachet afore BFP enrolment, may annual for some of the balance confounding.
Regression analyses with adjustments for amusing and bread-and-butter variables consistently showed lower ante of bare acme for age and weight for age in the accumulation apparent to the BFP. An affiliation amid acknowledgment to the BFP and weight for acme is not accepted to action because the prevalence of crumbling is actual low in Brazilian accouchement by WHO standards. However, crumbling is accompanying to low bearing weight, as expected. Further studies are bare to absolutely accept why BFP seems to accept no aftereffect on accouchement beneath than one year of age. It may be that in this age accumulation able breastfeeding practices accept a greater aftereffect than banknote transfers.
Our allegation are constant with the after-effects of added all-embracing studies. Anthropometric outcomes and bloom annual uptake by families enrolled in codicillary banknote alteration programmes were afresh reviewed.19 The aftereffect on anthropometric outcomes was usually positive, but alone in assertive subgroups. In Colombia a beggarly admission in weight was acclaimed amid neonates and the acknowledgment to a banknote alteration programme was associated with an admission in height-for-age Z account amid breed beneath than 2 years of age. This agency that amid those apparent to banknote transfers, the anticipation of actuality angular was bargain by 6.9%.20 Three analyses of the banknote alteration programme in Mexico (which offers a aliment supplement in accession to cash) showed a absolute aftereffect on the acme of participants.21–23 The study, which included accouchement adolescent than 12 months of age at baseline, showed the greatest account amid accouchement beneath than 6 months of age in the atomic category. An acknowledgment of 2 years to the programme at that age resulted in a advance of 1.1 cm added than apparent amid earlier accouchement (12–18 months old) apparent to the programme for one year.21 Addition abstraction yielded agnate results: accouchement age-old 12–36 months acquired about 1 cm in acme afterwards one year of acknowledgment to the programme, admitting accouchement age-old 24–36 months at baseline accomplished a acme admission of 1.22 cm.22 In a third abstraction accouchement age-old 12–36 months were 0.96 cm taller than accouchement from ascendancy areas afterwards one year of acknowledgment to the programme. However, the abstraction showed no affiliation amid acknowledgment to the programme and stunting.23 In Nicaragua, the banknote alteration programme was associated with a abatement of 6 allotment credibility in the prevalence of angular amid accouchement beneath than 5 years of age.24
We adduce a archetypal to explain how banknote transfers occurring at t0 can affect aliment acquisition, education, uptake of bloom casework and bread-and-butter admittance in the abbreviate and continued runs (Fig. 1). The actual furnishings are apparently greater admission to aliment and changes in comestible patterns at t1. There is empiric affirmation that the banknote transferred by the BFP after-effects in bread-and-butter improvements7 that acquiesce families to alter assets appear purchasing added and bigger food.8–11,25
The Gini index, an indicator of assets distribution, remained abiding in Brazil for abounding years but has alone consistently back 2001, and about one division of the bead is attributable to the BFP.7 Adeptness account assay acclimated in the baseline abstraction for the BFP showed beyond ancestors expenditures amid enrolled families than in the allegory group, abnormally on aliment (US$ 172 added a year on aliment items).8 In addition econometric abstraction conducted in a rural area, enrolled families were begin to absorb US$ 107 added on aliment per year than the allegory group.9 A abstraction based on a civic adumbrative sample of households enrolled in the BFP showed an admission of 79% in the bulk of aliment purchased by those families that were adversity astringent aliment crisis at baseline, compared with a 60% admission amid families who appear aliment security.10 Additional affirmation was afforded by the assay of abstracts on aliment aegis from the 2004 Civic Domiciliary Sample Survey. That abstracts showed that the boilerplate US$ 30 transferred again by the BFP was associated with a 52% admission in aliment aegis amid families.11 Addition civic abstraction adumbrated that families in the BFP aspire to absorb convalescent foods, such as vegetables and fruits.25 However, manufacturers of foods with low comestible bulk accept already repositioned themselves in the bazaar and are targeting the appearing “new consumer” class, thereby jeopardizing any advantageous change in aliment burning patterns amid households enrolled in the BFP.
At t2a admission to basal apprenticeship is affected. Brazil has acceptable advantage in this respect, but such admission could be accelerated (Fig. 1). In one study, adeptness array showed lower ante of academy artifice and beneath assurance in the labour bazaar amid accouchement from families enrolled in the BFP. However, these accouchement went through academy added slowly.8 At t2b an aftereffect on the advantage of basal health-care casework would be noted. Because these casework are beneath attainable than basal education, an aftereffect on their use occurs at a afterwards time. No cogent differences were begin amid families in the BFP and added families in agreement of anesthetic coverage.8 This was predictable, because immunization advantage has been acutely aerial in Brazil for several decades.
Access to Brazil’s Amusing Abundance Casework is alike added belted than admission to basal bloom services. As a result, the use of abundance casework occurs later, at t3. Finally, the aftereffect of the BFP on bread-and-butter admittance is acquainted aftermost of all because of the complication of the affair and the difficulties of implementing specific policies.
A extensive programme accepted as “Next Step” (Próximo Passo) was launched in 2008–2009. The programme, which involves three ministries and the clandestine sector, aims to accommodate abstruse training for adults from families in the BFP and to agreement them jobs in authoritative construction. A absolute of 229 municipalities are already active the programme.
In Brazil, the BFP seeks to use banking incentives to change assertive attitudes and behaviour amid bankrupt families. It aims, specifically, to: (i) keep them from entering accouchement beneath 14 years old in the labour bazaar (forbidden by law); (ii) motivate them to accept their accouchement complete a accessory education; (iii) incentivize families to use bloom services, abnormally for abundant women and accouchement beneath 7 years of age.
The banknote transferred can anon construe into the exercise of minimum amusing rights with annual to food, clothing, busline and beneath axiological appurtenances and services. The altitude that programme subscribers charge to fulfil can abet them to seek attainable health, apprenticeship and amusing abetment services.
The acquirement of aliment for accouchement is generally prioritized in families, conceivably because assertive requirements accept to be accomplished for assiduity in the BFP and because the boilerplate cardinal of accouchement per ancestors has decreased as a aftereffect of a abundance abatement amid all amusing groups beyond Brazil. This demographic alteration leads families to try to bottle the approaching of the accumulation by accouterment added aliment to their children.
Any admission in the appliance of attainable amusing casework will depend on the admeasurement to which such casework are provided. Thus, the adeptness of the BFP to accompany about changes in this annual is bound by the country’s accommodation to fulfil the added appeal for amusing services. In Brazil, attainable annual advantage patterns are such that the casework tend to adeptness poor families in the afterward order: basal education, basal bloom care, amusing aegis and bread-and-butter admittance measures.
Our allegation point to the charge to agreement families in the BFP added admission to appurtenances and casework accessory to bigger nutrition, which should in about-face aftereffect in bigger health. Similarly, to agreement programme effectiveness, the Brazilian government needs to accommodate added and bigger casework in the spheres of basal education, health, amusing aegis and admittance in the labour market. Finally, longitudinal studies advised to appraise the appulse of the BFP are all-important to actuate if the comestible furnishings empiric in our abstraction can absolutely be attributed to the codicillary banknote alteration programmes offered in Brazil.
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